The Art and Science of Optometric Communication:

A Practical Understanding of Binocular Vision and Visual Perceptual Testing

for Optometrists, Vision Therapists and Patients

COVD 2016

Philip Carl Bugaiski OD FCOVD FCSO

The Developmental Vision Center

10210 Berkeley Place Drive, Charlotte NC 28262

Outline

I.  Why do we need to think about “Communication”?

  1. Definition and etymology of “Communication”
  2. Knowledge and language of optometrists vs. knowledge and language of patients and their families
  3. Common communication breakdowns and their causes
  4. What do they look like
  5. Non-verbal cues
  6. Verbal cues
  7. Impact of choice of treatment approach
  8. Loss of communication
  9. The use of jargon
  10. Emphasizing findings instead of patients’ and families’ complaints
  11. Discussing treatment before patients and families understand the link between findings and symptoms

II.  Steps of communication

  1. Effective listening
  2. When does it start?
  3. Probing questions
  4. Start with “Tell me a little about what is going on with your child’s vision”
  5. Immediately learn their current understanding of “vision”
  6. Avoid the temptation to start explaining
  7. Related to typical vision complaints
  8. Blur
  9. Double vision
  10. Watery or red eyes
  11. Related to observable signs
  12. Squinting
  13. Eye rubbing
  14. Close, or frequent changes in working distance
  15. Leaning body, tilting head, coving one eye
  16. Related to reading
  17. Loss of place, skipping words, rereading lines
  18. Substituting words with similar letters
  19. Fatigue while reading
  20. Related to writing
  21. Poor penmanship
  22. Spelling errors
  23. Difficulty aligning numbers in columns
  24. Predictive questions
  25. Related to reading
  26. Difficulty recalling what has been reading
  27. Mismatch between listening and reading comprehension
  28. Mismatch between math number problems and story problems
  29. Related to writing
  30. Mismatch between verbal and written expression
  31. Forgetting ideas while writing them
  32. Writing as little as possible to complete work
  33. The value of predictive questions
  34. Trigger recognition that these behaviors may be linked to a vision problem
  35. What to do when you make a “wrong” prediction
  36. Brief explanation of the role of vision and what the patient has told you
  37. The value of demonstration versus verbal explanation
  38. A question related to the patient’s or family’s experience of the vision problem
  39. “What’s this been like for you?”
  40. Vision problems have an emotional impact
  41. Be the doctor that listens
  42. Take the next appropriate action
  43. When to use the above steps
  44. Triage phone call, patient evaluation, case presentation, treatment sessions, progress evaluations, communicating with and training other professionals, completing treatment
  45. The difference between effective and efficient communication

III.  Optometric testing that communicates

  1. Relating oculomotor, binocular, and accommodative findings to symptoms
  2. “Tests” can be failed, “Experiments” are fun
  3. Instruction sets and findings are in lay terms
  4. Visual acuity
  5. Cover test
  6. Objective vs subjective phoria
  7. Pursuits
  8. Include cognitive loading, relate to writing symptoms
  9. Saccades
  10. Relate to reading and attention
  11. By this point in testing, findings start to coincide with symptoms
  12. “No wonder you have trouble with …” “Your eyes don’t know how to do their jobs yet.”
  13. Nearpoint of convergence, nearpoint of discomfort
  14. Wealth of information from CITT
  15. Stereopsis
  16. Relate to NPC, posture, stamina, attention
  17. Color vision
  18. Relate to figure ground
  19. Refractive status
  20. Distance retinoscopy vs autorefractor vs subjective refraction
  21. In-instrument phorias
  22. Repeatability and stability
  23. Vergence ranges – distance and near
  24. Discomfort/blur/break/recovery/presence of SILO or SOLI
  25. Accommodative facility
  26. First disruptive lens/first sustained blur/recovery
  27. Accommodative sufficiency
  28. Minus lens vs push-up
  29. Retesting as needed with probe lenses
  30. Effective vs efficient optometric evaluation
  31. Repeat probing and predictive questions during “experiments” as needed
  32. Repeat brief demonstrations to explain
  33. Ask about the day-to-day experience of the problems related to what you find during the evaluation
  34. Take the next appropriate action (e.g. lenses, vision therapy, further evaluation)

IV.  Visual perceptual testing that communicates

  1. DEM and/or King-Devick
  2. Test of Visual Perceptual Skills 3rd edition
  3. Visual Discrimination
  4. Visual Memory
  5. Visual Spatial Relations
  6. Visual Form Constancy
  7. Visual Sequential Memory
  8. Visual Figure-Ground
  9. Visual Closure
  10. Motor-Free Visual Perception Test 4th edition
  11. Global score vs scores for specific abilities
  12. Detroit Test of Motor Speed and Precision
  13. Wold Sentence Copy
  14. Beery-Buktenica Developmental Test of Visual-Motor Integration
  15. Short and full formats
  16. Visual perception and motor coordination supplements
  17. Rosner Test of Visual Analysis Skills
  18. Piaget Test of Right-Left Concepts
  19. Gardner Left-Right
  20. Execution Subtest
  21. Recognition Subtest
  22. Birch-Belmont Test of Visual-Auditory Integration
  23. The value of observational data combined with standardized test scores

V.  Communicating during the conference

  1. “What is your current understanding of what we have found so far?”
  2. The value of listening vs explaining
  3. Demonstrations that communicate the impact of vision problems
  4. Up-Down Reader
  5. Double-Vision Demo
  6. Nearpoint of Discomfort
  7. Review details of specific tests that relate to specific complaints, again in common terms
  8. Provide insights into treatment as informed by data and observations during evaluations
  9. “Is there anything that doesn’t make sense?”
  10. Written report for patient, family, referral source, doctors, teachers, etc
  11. Include symptoms, data, and connections between them

VI.  Connecting optometric findings with other professional assessments

  1. Occupational therapy
  2. Sensory defensive or sensory seeking
  3. Vestibular and proprioceptive problems
  4. Fine motor and/or gross motor difficulties
  5. Physical therapy
  6. Balance issues
  7. Bilateral coordination delays
  8. Speech and language therapy
  9. Impact of convergence and fusion problems
  10. Visual listening
  11. Psychology
  12. Weschsler Intelligence Scale for Children 3rd edition (WISC-III)
  13. Woodcock-Johnson Tests of Cognitive Ability 4th edition
  14. Verbal vs non-verbal learning problems
  15. Difficulties with processing speed, working memory
  16. Do diagnoses lead to accommodations or to remediation?
  17. Education
  18. Hallmark signs of learning-related vision problems
  19. Ineffectiveness of academic remediation when vision problems are present
  20. Demonstrations for educators

VII.  Question and Answer Cases

  1. Your probing questions?
  2. Your predictive questions?
  3. What findings might you expect?
  4. How do you relate findings to symptoms?
  5. JR, 8 year-old female, “The Avoider”
  6. BB, 8 year-old female, “The Struggler”
  7. How can 2 cases have very similar test data yet very different symptoms?
  8. DJ, 12 year-old male, very high grades in some classes, very low in others
  9. What does a developmental optometrist do with “normal” to “above-average” findings
  10. AC, 55 year-old male, brain injury survivor
  11. JJ, 62 year-old female, Mal de Debarquement Syndrome